Business requirements

The business commitment: problem, objective, boundaries, requirements, measurable acceptance and release ownership.

Product decision
Prioritize reliable claim completion and provider identity before increasing automation coverage.

Document type

Business requirements

Status

Portfolio sample · written from my healthcare claims experience

Product decision

Prioritize reliable claim completion and provider identity before increasing automation coverage.

Portfolio sample from my healthcare product experience. Requirements, thresholds and review records are illustrative; they are not employer documents or historical sign-offs.

Problem statement

Paper CMS-1500 and UB-04 claims require repetitive entry before electronic processing. Missing provider names and inconsistent address representations create additional resolution work. A faster extraction step creates limited value if the resulting claim still waits for manual correction downstream.

Objective and evidence

Reduce end-to-end manual handling for supported claims while keeping unresolved work visible and recoverable. My claims automation work converted scanned forms into EDI 837 transactions and supported auto-adjudication: more than 400,000 paper claims converted to EDI 837, an 80-person team redeployed and about $1M a year saved. The provider API and platform replacement are separate experiences that inform these sample requirements.

1. more than 400,000 paper claims converted to EDI 837
2. 80-person team redeployed
3. about $1M a year saved

Explore the Paper-to-EDI process above

Users and intended outcomes

Claims operators need a complete, traceable work item; provider-data teams need actionable match exceptions; receiving systems need valid transactions; product and operations need trustworthy cost, speed and quality reporting. Customer care needs a processing status it can explain accurately.

1. Claims operators need a complete, traceable work item
2. provider-data teams need actionable match exceptions
3. receiving systems need valid transactions
4. product and operations need trustworthy cost, speed and quality reporting
5. Customer care needs a processing status it can explain accurately

In scope / out of scope

The primary release covers a defined medical-claims cohort. The integration platform migration has a separate scope and release decision.

In scope	Out of scope
CMS-1500 / professional and UB-04 / institutional intake	Additional form types without an explicit contract and validation.
OCR extraction, required-field validation and authorized correction	Inferring missing clinical facts or approving coverage from an OCR score.
Provider normalization and authorized central-source resolution	Credentialing, network eligibility or prescriber authority inferred solely from an identity match.
Valid 837 handoff, acknowledgement tracking and reconciliation	Changing benefit policy, clinical judgment or receiving adjudication rules.
Role-based exception handling and operational reporting	Retail-pharmacy NCPDP processing within this medical-claims release.

Stakeholders and decision rights

I connect the business outcome to the people accountable for its consequences.

Partner	Decision or evidence
Product	Outcome, option comparison, MVP scope, priorities and acceptance contract.
Operations & customer care	Usable exceptions, staffing, training, status language and escalation ownership.
Engineering, vendor & design	Extraction/interface feasibility, source visibility, contract tests and recovery.
Provider-data & claims specialists	Matching evidence, authorized correction and downstream transaction interpretation.
Security, legal & compliance	Permitted data use, access, retention, partner obligations and release evidence.
Patient safety & clinical partners	Review plausible downstream consequences and boundaries requiring professional judgment; administrative gains alone do not establish clinical benefit.

Business requirements

P0 defines the minimum releasable commitment.

ID / priority	Requirement	Business acceptance
BR1 · P0	Reduce repetitive entry for supported valid claims	A valid claim progresses from source to receiver without avoidable re-entry.
BR2 · P0	Resolve provider identity on supported evidence	Uncertain identity remains visible; normalization cannot silently select a provider.
BR3 · P0	Account for the complete intake inventory	Each unique received claim has exactly one current state and a traceable disposition.
BR4 · P0	Support safe recovery and platform continuity	Retries and authorized replays do not lose or duplicate live transactions.
BR5 · P0	Make operations accountable and usable	A held claim has a reason, queue, age and a permitted route to resolution.
BR6 · P0	Measure value after rework	Cost and speed reporting includes correction effort, held work and downstream defects.

Functional requirements and Given / When / Then acceptance

The functional specification expands these contracts with response semantics and boundary cases.

Requirement	Given	When	Then
FR1 · Supported forms	A complete CMS-1500 or UB-04 source is received	The intake service classifies it	Create a traceable claim record and select the professional or institutional mapping; quarantine unsupported or unreadable forms.
FR2 · Extraction & correction	A required field is missing, uncertain or inconsistent with the source	An authorized operator reviews the candidate	Display the source beside the field; record the correction and revalidate before the claim can advance.
FR4 · Provider resolution	The authorized central source has current, uniquely supported provider evidence	The API resolves the request	Return the matched provider reference, evidence version and reason; return distinct missing, no-match, ambiguous or stale statuses otherwise.
FR5 · EDI validation	A complete reviewed claim has resolved required provider evidence	The applicable 837P or 837I transaction is generated	Validate against the applicable implementation and receiver contract; block invalid transactions and return an actionable field-level reason.
FR6 · Adjudication handoff	A validated claim is authorized for the receiving adjudication system	The transaction is submitted and acknowledged	Persist submission and acknowledgement separately; update final disposition only from the receiving system’s adjudication result.
FR7 · Retry & duplicate protection	A request times out or is repeated with the same processing identity	The service checks status or retries	Preserve identity, inspect known receiver status and prevent an unintended second claim submission; do not treat silence as failure.
FR9 · Authorization & audit	An actor requests claim access, correction or export	Their identity and permissions are evaluated	Allow only the permitted operation and record the action; deny unauthorized access without exposing protected values in errors or logs.
FR10 · Exception ownership	A claim is held, rejected or awaiting a confirmed result	Operations opens the exception queue	Show current state, reason, accountable queue and age; a resolved correction re-enters validation with its source history intact.

Metrics requirements

Use the same event definitions in the product, reporting and business review.

ID	Measure / definition	Decision
MR1 · Automation	Distinct eligible claims reaching a final receiver disposition without manual handling / all eligible received claims in the same cohort; report immature pending cohort separately	Decide whether to expand eligibility.
MR2 · Cost	Allocated extraction, compute, support and manual correction cost / distinct completed claims in the same period; report pending backlog alongside it	Identify whether work was removed or shifted.
MR3 · Speed	Received-to-final-disposition elapsed time p50/p95, plus extraction, lookup and acknowledgement stage times	Locate the bottleneck before buying more capacity.
MR4 · Defects	False provider matches, EDI rejection, duplicate submission and correction rates with explicit denominators	Stop expansion when a value gain masks quality loss.
MR5 · Accountability	Unique intake inventory reconciled to mutually exclusive current states; report unresolved age and unassigned queues	Expose missing work and operating gaps.

Nonfunctional and safety requirements

The values below are acceptance targets for this sample, separate from reported historical outcomes.

Requirement	Acceptance evidence
Access & data protection	Authorized role checks cover read, correct, submit and export; sensitive values excluded from routine logs; retention follows an approved policy.
Provider API performance	At a declared 50 requests/second sample load, p95 ≤500 ms; publish source-query/cache breakdown and error rate.
Recoverability	Injected timeouts and replay retain one processing identity and produce no unintended duplicate live submissions.
Traceability	Every test claim retains source, validation version, provider resolution and state-change history.
Safety boundary	No OCR or matching component decides clinical necessity, benefit approval or medication appropriateness.

Dependencies, assumptions and risks

Dependencies include representative forms, approved receiver specifications, an authorized current provider source and staffed review queues. The principal risks are extraction error, false matching, stale reference data and silent loss during recovery. I keep the eligible cohort bounded until the complete path and its exceptions are demonstrated.

1. extraction error
2. false matching
3. stale reference data
4. silent loss during recovery

I keep the eligible cohort bounded until the complete path and its exceptions are demonstrated.

Traceability and release decision

BR1 → FR1/2/5/6 → Q1–Q4. BR2 → FR3/4 → Q5–Q7. BR3/4 → FR6/7/8 → Q8–Q10. BR5 → FR9/10 → Q11–Q12. BR6 → MR1–MR5 → Q12 plus the measurement review. The sample release gate requires executed QA, operator UAT, accountable support and reconciled inventory; the portfolio is not a historical sign-off record.

CMS: professional claims and CMS-1500 ↗ · CMS: institutional CMS-1450 / 837I ↗ · CMS: adopted transaction standards ↗

1. executed QA
2. operator UAT
3. accountable support
4. reconciled inventory

the portfolio is not a historical sign-off record